Fine needle aspiration biopsy of metastatic melanoma. A morphologic analysis of 174 cases

The prognostic and therapeutic decisions in cases of metastatic melanoma depend upon the morphologic documentation of metastatic disease, which may rapidly and accurately be done by fine needle aspiration (FNA) biopsy of clinically suspicious lesions. The tumor cells derived from malignant melanomas demonstrate a wide range of appearances, however, and other neoplasms may be mimicked. Furthermore, additional neoplasms of other types are more frequent in melanoma patients: the possibility of a new primary tumor must be considered if the morphology of the tumor cells is uncharacteristic. Therefore, a study was undertaken to analyze the morphologic changes seen in FNA biopsy specimens from metastatic malignant melanoma and to determine which features could be the most useful in establishing a definitive diagnosis. A total of 174 consecutive cases, comprising 151 malignant aspirates and 23 inconclusive aspirates, were reviewed. The most significant features for identification of melanoma over other tumor types were the cell shape and nuclear position, the presence of numerous isolated neoplastic cells and occasional binucleated or multinucleated cells. Intracellular melanin in neoplastic cells was diagnostic when present, but it was absent in 60% of the cases. Macronucleoli and/or intranuclear cytoplasmic invaginations were characteristic but variable features. Morphology was also found to vary by site and cell type. Lung aspirates were less cellular and more likely to contain melanin. Aspirates of subcutaneous nodules were more often composed of spindle-shaped cells or of other variant cell types. Lymph node aspirates more often yielded epithelioid cells with macronucleoli and/or intranuclear invaginations. Spindle-cell melanomas usually demonstrated inconspicuous nuclei and rarely showed enlarged nucleoli. Epithelioid-cell tumors contained multinucleated cells and areas of cell wrapping more frequently than did spindle-cell tumors. The findings in this study emphasize that a full awareness of the spectrum of morphologic presentations of metastatic melanoma as well as of the clinical history are needed for greater precision in its diagnosis and for avoidance of the pitfall of misdiagnosing nonmelanomas with similar appearances.

Defective release of vascular plasminogen activator in patients with gynecologic malignancies

Vascular plasminogen activator release was measured in 176 women with gynecologic malignancies and 92 normal women. Releasable plasminogen activator was considerably decreased in the patients (P less than 0.00001 by Wilcoxon's rank sum test) with 59.1% releasing less than 0.04 Committee on Thrombolytic Agents units per milliliter of plasma after a standard venous occlusion procedure. The data were also stratified by tumor location, demonstrating that this decrease in releasable vascular plasminogen activator was seen for ovarian (P = 0.0001), endometrial (P = 0.0017), and cervical (P = 0.0063) cancers. Postoperative deep vein thrombosis, with or without pulmonary emboli, occurred in 28 patients (15.9% incidence). These patients also demonstrated markedly lower levels of releasable vascular plasminogen activator compared to control subjects (P less than 0.0001). It is suggested that defective release of vascular plasminogen activator contributes to a hypercoagulable state in patients with gynecologic malignancies and predisposes to postoperative thromboembolic complications.

Increased releasable vascular plasminogen activator and a bleeding diathesis

A 66-year-old man with metastatic prostatic carcinoma treated with high-dose (5 mg) diethylstilbestrol therapy underwent orchiectomy to allow discontinuation of estrogen. An extensive ecchymosis developed postoperatively in an area covered by elastic dressing tape; subsequently, it was learned that the patient had a recent history of frequent ecchymoses with mild trauma that proceeded to vesiculation. His alpha2-antiplasmin level was 132 percent, fibrin split products 4 micrograms/ml, and fibrinogen 293 mg/dl; routine coagulation results were normal. However, the level of releasable vascular plasminogen activator in a specimen drawn prior to surgery was 3.6 CTA units/ml, the highest value ever reported in this laboratory.

Vascular plasminogen activator levels and thromboembolic disease in patients with gynecologic malignancies

Vascular plasminogen activator levels were measured preoperatively in 66 women with gynecologic malignancies. These levels were compared to levels in a matched control group of 84 women and to the incidence of postoperative venous thromboembolic disease in the patient group. Significantly lower levels of plasminogen activator were measured in patients who developed thrombotic complications (p = 0.0014). When results were stratified according to tumor location, patients with ovarian carcinoma had significantly higher activator levels than those found in control subjects (p = 0.0072), and significantly lower levels were associated with endometrial malignancy (p = 0.0140). Measurement of releasable plasminogen activator before operation may be an effective, noninvasive means of identifying patients potentially at risk for venous thromboembolic disease. Postoperative measurement of plasminogen activator may eventually find a role in monitoring tumor therapy and recurrence.

An extensive solitary xanthoma of the temporal bone, associated with hyperlipoproteinaemia

A rare case of a solitary xanthoma deposit in the temporal bone associated with a primary type V (WHO classification) hyperlipoproteinaemia is presented. Only one other similar case has been found in the literature, and this was also associated with a hyperlipoproteinaemia. This earlier case was most probably a type V although it is difficult to be sure because of the slightly limited information available.